An example of how you can start imaginal exposure. The first step to start ERP therapy is to brainstorm all thoughts and compulsive rituals that distress you.
Write down as many as you can and highlight next to them, classifying the symptoms as mild, moderate or severe. Mild symptoms cause less than 30% distress; symptoms causing 30-60% are classified as moderate, and over 60% distress are classified as severe. Use a tabular column under the headings mild, moderate, and severe and tabulate your symptoms according to their severity. You could have a list of symptoms of increasing distress to start with. For example., if you are having intrusive images of the death of someone you love a lot, you might want to grade the thoughts according to distress like below:
Grade 1– Write and listen to the script of your loved one in pain.
Grade 2– Write and listen to the script of your loved one dodging a car in an accident.
Grade 3 – Write and listen to the script of your loved one chased and bitten by a dog.
Grade 4 – Write and listen to the script of your loved one bleeding from a wound.
Grade 5 – Write and listen to the script of your loved one in a hospital.
Grade 6 -Write and listen to the script of your loved one hit on the street by a car.
Grade 7– Write and listen to the script of your loved one almost dying.
Grade 8– Write and listen to the script of your loved one in the graveyard.
Now, start with Grade 1 and write a script. Read the script five times daily or record it and listen thrice daily on a loop for 10 minutes. You might be very distressed, so we begin with Grade 1.
Avoid any compulsive rituals or reassurance-seeking or safety behaviours. Keep repeating the grade 1 imaginal exposure till you learn that it is safe to have an intrusive thought that is distressing, and understand that it is safe to experience panic. You can still function if you are distressed or panicked. This new learning, known as inhibitory learning, which we have seen in detail in previous blogs, is critical to the success of ERP as a therapeutic strategy.
Only move on to the next grade once you have completed grade 1, even if it takes a few weeks. ERP is like exercising a muscle, gaining strength, and learning a new skill. It can be a life skill to learn. We have now seen an example of how you can conduct imaginal exposure in a graded fashion. In the next blog, we will see an example of how you can conduct a situational exposure in a graded fashion.
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